Corridor Door Latching Deficiencies
Penalty
Summary
The facility failed to ensure that corridor doors positively latched in their frames, which affected two of the four levels in the facility. During an observation conducted on January 27, 2025, between 12:00 p.m. and 2:30 p.m., it was noted that the door to resident room 219 was binding in the frame and could not close properly. This issue with the door's functionality could potentially compromise the safety and security of the residents in that area. Additionally, the door to resident room 327 was found to be difficult to open due to the door handle not releasing the latch. This malfunction could hinder the ease of access to the room, potentially affecting the timely response to resident needs or emergencies. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
1. The doors for rooms 219 and 327 were immediately repaired to ensure they are in proper working order. 2. Resident room doors audited to ensure they remain in proper working order. 3. Education will be provided to ensure proper compliance with this regulation. 4. An audit of five resident room doors will be conducted to ensure they are in proper working order. Audit will be done 2x a month for 2 months and 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.